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Role of Governance in Infection Prevention and Control Policy and
Strategy Implementation in the Public Health Sector in South Africa
by
Moleboheng Emily Binyane
2004030637
Submitted in partial fulfilment of the requirements for the Magister Degree
in
Governance and Political Transformation in the
Governance and Political Transformation Programme at the
University of the Free State Bloemfontein
2018
i
Author’s declaration
I, Moleboheng Emily Binyane, declare that the mini-dissertation that I herewith submit for the Master’s Degree in Governance and Political Transformation at the University of the Free State is my independent work, and that I have not previously submitted it for a degree at another institution of higher education.
ii
Acknowledgements
First and foremost, I acknowledge Almighty God for enabling me to qualify to do this study and for giving me the wisdom, strength and ability to carry out the duties of the study from the beginning to completion. It was not easy, but God made it possible.
I am very grateful to my supervisor, André Janse van Rensburg, for his endless support, patience, motivation, and understanding. His dedication to this work gave me hope to continue even though I wanted to quit. He worked through this dissertation even during his hospitalization. I have never seen this kind of commitment in my life. I am at a loss for words to show my appreciation for his ability to impart his knowledge to someone like me who was clueless in respect of research and writing in the Social Sciences because of my deep background in the Medical Sciences.
I am very thankful to my sisters, Mampho Julia Sediane and Ntsoaki Portia Mokhothu for their continuous support and motivation. My granddaughter, Katleho Precious Mokhothu for keeping me happy and cheerful during my studies. Their love gave me hope to carry on. I dedicate this work to my late parents, my father, Pule Edward Binyane and my mother, Nkutloang Leah Binyane; I thank them so much for showing me the path to education and giving me hope to carry on even in their absence. I will never stop loving them.
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Abstract
Reports have shown that the challenges of policy implementation in South Africa (SA) are the main weakness of the health system. National and provincial guidelines for infection control (IC) have been adapted for the implementation of IC practices in SA. However, research has revealed poor infection prevention and control (IPC) in public healthcare in SA.
There is no evidence to what extent the IPC guidelines have been implemented and whether governance has played a role in the implementation of the National Infection Prevention and Control Policy and Strategy (NIPCPS; 2007). The aim of the study was therefore to explore how governance plays a role in the implementation of NIPCPS in SA’s public healthcare sector. The study employed a qualitative research approach as the focus was on documenting the shortages of antimicrobial drugs, space and equipment, as well as the maltreatment of patients with infectious diseases by healthcare workers in SA, and the impact of this on IPC. Data was collected through the internet and relevant newspaper articles were used for the study. The study findings were presented using the thematic approach and inductive and deductive approaches were integrated to form a coherent narrative. Deductive analysis involved the application of a framework for assessing governance of the health system by Siddiqi et al. (2009).
The findings of case study analysis and framework application revealed shortages of antimicrobial drugs, space and equipment, as well as the maltreatment of patients by HCWs in public healthcare in SA several years post the launch of NIPCPS. Shortages of antimicrobial drugs and the maltreatment of patients by HCWs are due to the lack of accountability by DoH. HCWs in SA still lack training in IPC, they have poor job descriptions, and their participation in policymaking and implementation is inadequate. Other healthcare facilities in SA still lack institutional IPC guidelines.
Shortages of antimicrobial drugs, space and equipment, and the maltreatment of patients by HCWs have a negative impact on IPC. The state of affairs exposes patients to infectious diseases, puts them at risk of developing drug resistance and may lead to nosocomial infections outbreaks. It also exposes HCWs to infectious diseases, hampers their jobs by delaying important medical procedures and subjects them to medical errors and wrong prescriptions. Further studies are warranted to explore the topic of research.
Key words: Governance, antimicrobials, equipment, space, healthcare, public, SA, IPC, NIPCPS, nosocomial infections
iv Table of Contents Author’s declaration ... i Acknowledgements ... ii Abstract ... iii Table of Contents...iv List of Figures...viii List of Tables...viii Abbreviations ... ix
Chapter 1: Introduction and problem formulation ... 1
1.1Introduction and background ... 1
1.2 Problem statement ... 5
1.3 Aim and objectives ... 6
1.4 Theoretical framework ... 6
1.5 Structure of this dissertation ... 7
1.6 Summary ... 8
Chapter 2: The health policy and NIPCPS, public healthcare in South Africa, challenges, and governance ... 9
2. Introduction ... 9
2.1 Policy, public policy and health policy ... 9
2.1.1 Policy implementation processes ... 10
2.1.2 Health-related policy introduction and implementation in post-apartheid SA ... 11
2.2 The healthcare system in general ... 19
2.3 SA's public health care system……….23
2.3.1 Quadruple disease burden crippling SA’s public healthcare system……….………23
v
2.3.2 IC of communicable diseases as part of the burden crippling
SA’s public healthcare system ... 24
2.3.2.1 IC globally ... 24
2.3.2.2IC SADAC ... 25
2.3.2.3 IC SA ... 26
2.3.2.4 Lack of antimicrobial drugs and IC ... 27
2.3.2.5 Lack of healthcare space and equipment and IC ... 27
2.3.2.6 Poor treatment of patients by health workers, and IC ... 27
2.3.3 Other challenges faced by SA’s public healthcare system ... 28
2.4 Post-apartheid health service delivery reforms ... 29
2.4.1 Primary healthcare... 29
2.4.1.1 Development of PHC in post-apartheid SA and current PHC structure ... 30
2.4.1.2 Challenges that have plagued the PHC system during the past 2 decades ... 31
2.4.1.3 Current reforms in response to challenges and PHC re-engineering . 33 2.4.2 Secondary and tertiary level of care ... 35
2.5 Structures of governance in the South African health system ... 37
2.6 Summary ... 41
Chapter 3: Research methodology ... 42
3. Introduction ... 42
3.1 Research approach and design ... 42
3.2 Data collection... 43 3.2.1 Sampling………..………43 3.3 Data analysis ... 43 3.4 Data quality ... 44 3.4.1 Trustworthiness ... 44 3.4.2 Triangulation ... 44
vi
3.5 Ethics ... 44
3.6 Summary ... 45
Chapter 4: Study findings ... 46
4. Introduction ... 46
4.1 Application of the health system framework by Siddiqi et al. (2009) to assess the implementation of the NIPCPS at public healthcare facilities in SA ... 46
4.1.1 Strategic vision ... 46
4.1.2 Participation and consensus orientation ... 47
4.1.3 Accountability ... 48
4.1.4 Ethics ... 49
4.1.5 Effectiveness and efficiency ... 50
4.1.6 Rule of Law ... 50
4.2 Summary ... 51
4.3 Multiple-case analysis ... 52
4.3.1 Multiple-case analysis of the shortage of antimicrobial drugs at public healthcare facilities in SA ... 53
4.3.1.1 Shortage of drugs at public healthcare facilities in SA ... 53
4.3.1.2 Civil society’s response to reported shortages of drugs ... 53
4.3.1.3 HCW’s response to reported shortages of drugs ... 54
4.3.1.4 Department of Health’s response to reported shortages of drugs ... 55
4.3.2 Multiple-case analysis of the shortage of space and equipment in public healthcare in SA ... 56
4.3.2.1 Shortage of medical equipment at public healthcare facilities in SA ... 57
4.3.2.2 Shortage of space (overcrowding) at public healthcare facilities in SA ... 57
4.3.2.3 Civil society’s response to reported shortages of medical equipment and space ... 58
vii
4.3.2.4 HCW’s response to reported shortages of medical equipment and
space ... 58
4.3.2.5 Department of Health’s response to reported shortages of medical equipment and space ... 59
4.3.3 Multiple-case analysis of maltreatment of patients who have infectious diseases by HCWs at public healthcare facilities in SA ... 60
4.3.3.1 Maltreatment of patients by HCWs at public healthcare facilities in SA ... 61
4.3.3.2 Death and injury of patients at public healthcare facilities in SA as a result of reported maltreatment ... 61
4.3.3.3 Civil society’s response to reported maltreatment of patients at public healthcare facilities in SA ... 62
4.3.3.4 The Department of Health’s response to reported maltreatment of patients at public healthcare facilities in SA ... 62
4.4 Summary ... 63
Chapter 5: Discussion, conclusion, recommendations and study limitations . 64 5. Introduction ... 64
5.1 The role of governance in the implementation of the NIPCPS in the public healthcare sector in SA ... 64
5.1.1 Strategic vision ... 64
5.1.2 Participation and consensus orientation ... 65
5.1.3 Accountability ... 66
5.1.4 Effectiveness and efficiency ... 66
5.1.5 Rule of Law ... 66
5.2 Shortages of antimicrobial drugs and their consequences for IPC in public healthcare in SA ... 67
5.3 Shortages of equipment and space, and their consequences for IPC in public healthcare in SA ... 68
viii
5.4 Maltreatment of patients who have infectious diseases by HCWs and
its consequences for IPC in public healthcare in SA ... 69
5.5 Conclusion ... 70 5.6 Recommendations ... 71 5.7 Study limitations ... 72 References ... 73 Appendix A ... 84 Appendix B ... 90 Appendix C ... 97 List of Figures Figure 1.1: Multiple case study analysis and theoretical framework application..…...7
Figure 2.1: The public policy cycle...11
Figure 2.2: Policies and regulations that form part of NIPCPS formulation and implementation...16
Figure 2.3: A picture of PPE...18
Figure 2.4: Health system performance model: relationship between key functions and respective objectives...20
Figure 2.5: Health system building blocks...22
Figure 2.6: Alternative perspective to health system performance...23
Figure 2.7: Local clinic...31
Figure 2.8: A proposed model for PHC...32
Figure 2.9 Framework of Health Governance...38
Figure 2.10: The structure of the South African Health System...39
List of Tables Table 2.1: Post-apartheid policies and legislation from 1994 to the launch of NIPCPS (2007)...13
ix
Abbreviations
AIDS Acquire Immunodeficiency Syndrome
AMR Antimicrobial Resistance
ARV Antiretroviral
CHC Community Health Centre
CSOs Civil Society Organizations
DHC District Health Council
DHS District Health System
DoH Department of Health
DPW Department of Public Works
HAI Hospital Acquired Infections
HCS HealthCare System
HCWs Healthcare Workers
HIV Human Immunodeficiency Virus
HRH Human Resources for Health
IC Infection Control
ICU Intensive Care Unit
IPC Infection Prevention and Control
MDR-TB Multidrug Resistant Tuberculosis
MECs Members of Executive Council
MTB Mycobacterium Tuberculosis
NIPCPS National Infection Prevention and Control
Policy and Strategy
NDoH National Department of Health
x
NHI National Health Insurance
NHMC National Health Management Committee
NHS National Health System
NIs Nosocomial Infections
PHC Primary Healthcare
PPE Personal Protective Equipment
SA South Africa
TAC Treatment Action Campaign
TB Tuberculosis
WHO World Health Organization
1
Chapter 1: Introduction and problem formulation
This chapter provides an overview of the study, and describes the problem statement, aim and objectives of the study, along with a governance framework.
1.1 Introduction and background
Reports have demonstrated that infection prevention and control (IPC) is not being practised enough in South Africa (SA) (Visser et al., 2011), when compared with the World Health Organization (WHO) levels of infection control (IC) (Engelbrecht & Janse van Rensburg, 2013). As a result, research has raised concerns regarding the implementation of practices of infection control at public health facilities in SA (Engelbrecht & Janse van Rensburg, 2013), placing emphasis particularly on the main policy of IC, the National Infection Prevention and Control Policy and Strategy (NIPCPS; 2007). An assessment of the implementation of this policy in primary healthcare (PHC) and tertiary healthcare will inform stakeholders about the safety of clinics and hospitals for patients and healthcare workers (HCWs).
The basic right to healthcare, a basic human right embedded in section 27 of the SA Constitution 1996 (Chapter 2) is the foundation of the current healthcare system (HCS) in SA (Dambisi & Modipa, 2009). The HCS in SA comprises the public and private health sectors (Dambisi & Modipa, 2009). Public healthcare is largely offered by the government (Department of Health) which provides the finances that are obtained from the taxpayers, while the private sector provides for-profit health services (Biermann, 2006). The public sector provides services to approximately 84% of the population who are mostly black and poor (Naidoo, 2012).
IC is an important component of delivery care, and it needs an appropriately functioning health system (Hussein et al., 2011). However, SA’s health system currently buckles under a quadruple burden of diseases. It includes a high prevalence of Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) which exist in a complex relationship with tuberculosis (TB); high levels of maternal mortality; and elevated levels of non-communicable diseases which are escalated by risk factors associated to life-style, violence, injuries and trauma (Naidoo, 2012). Maternal sepsis is a leading cause of maternal mortality (Hussein et al., 2011). It is described as a disease burden in women by the WHO (2008) and is a consequence of deteriorating IC practices (Hussein et al., 2011). Poor TB IC is partly a result of escalated TB incidence in public healthcare in SA (Engelbrecht & Van Rensburg, 2013). The TB/HIV treatment integration is a basis for the control of the increase in the incidence of TB and HIV co-infection, but it remains poorly implemented, and plans
2
for strengthening the integration of services such as antiretroviral (ART) are necessary (Churchyard et al., 2014). In reaction to this disease burden, the National Department of Health (NDoH) of SA has introduced several national pertinent policy documents including the South African Draft NIPC guidelines for TB, multidrug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB), and the NIPCPS (Engelbrecht & Van Rensburg, 2013).
The NIPCPS (2007) highlights that IC is a crucial issue because it places a huge burden of cost on the health services in that it extends hospitalization, increases the antimicrobial drugs usage, and it escalates the number of remedial interventions per patient ( NIPCPS, 2007). A rational antibiotic use is one of the IPC measures (NIPCPS, 2007). Shortages of antimicrobial drugs are an important issue in public health and the delivery of medical care in that they result in poor IC by shrinking the pipeline of new antibiotics, and increasing drug resistance, for example, interrupting the antiretroviral treatment can result in treatment failure and drug resistance (Quadri et al., 2015).
Antibiotic resistance is a serious threat in hospitals and it results in higher morbidity and mortality when caused by drug-resistant organisms (Hosein et al., 2002), such as
Mycobacterium tuberculosis (MTB) with resistant strains causing MDR-TB (Andrews et al.,
2007). It can also be difficult to manage because in the case of an outbreak, providing healthcare to cohorts of patients is difficult, and would result in hospital ward crowding and would add to a shortage of beds, which is a persistent problem (Hosein et al., 2002).
Despite the knowledge and distribution of the NIPCPS in respect of the implementation in public healthcare, the shortage of antimicrobial drugs is still a problem in SA. Bateman (2013) and Schowalter and Conradie (2012) reported shortages of antimicrobial drugs in SA. This places more emphasis on the implementation of the NIPCPS.
Another important challenge to effective healthcare delivery is hospital-acquired infections (HAIs) (Kaier et al., 2012). In an effort to minimize nosocomial infections (NIs) that prolong hospitalization and require high remedial interventions, contact precautions are taken which require the isolation of infected patients in order to control the spread of resistant organisms in hospitals (Hosein et al., 2002). However, overcrowding in hospitals might compromise IC measures (Visser et al., 2011), and this highlights the importance of the implementation of the current NIPCPS document.
It is documented in section 8.3 on page 9 of the NIPCPS document that the rights of patients will be upheld, but the patients are still neglected and maltreated in public healthcare
3
facilities. Jewkes et al. (1998), Andrews et al. (2007) and Human et al. (2010) report on the maltreatment of patients by HCWs in public healthcare in SA.
Section 6 of the NIPCPS document describes the consequences for public healthcare and its staff members should they expose the patients to the risk of infection. Consequences include litigation against the state; disciplinary action against the staff members by the professional health council; criminal or civil prosecution of the individual staff member; and loss of public confidence in the particular health facility (NIPCPS, 2007). The issues of patient neglect and IC are important, which require the close compliance with the implementation of the current NIPCPS document.
The rational use of antibiotics, patients’ isolation and adhering to patients’ right to healthcare are the important components of the NIPCPS. A shortage of antibiotics exposes patients to drug resistance, the lack of hospital beds (medical devices) hinders patients’ isolation and the maltreatment of patients, who have communicable diseases, are the valid issues that need to be looked at in the investigation of NIPCPS implementation. The reason is that all these problems might result in an elevated cost for public healthcare due to litigation, antibiotic resistance, and unmanageable outbreaks. Looking at the implementation of this particular policy it might be essential to also help minimize the risks of exposing the patients and staff members of public healthcare to infections.
Post-apartheid SA is still facing the challenge of controlling infections such as HIV and TB co-infection, which are declared a national emergency, but the government response has been a poor implementation of policies and programmes (Abdool-Karim et al., 2009). These problems are blamed on leadership changes in the Ministry of Health and policy change in the management of HIV and TB, disease of life style, injury and violence as well as maternal and child death (Visagie and Schneider, 2014). As a result, policy development in the integrated HCS fails to direct the translation of policy principles into service delivery, and this is blamed largely on the lack of clear direction and accountability at district level (Dookie & Singh, 2012). According to Dookie and Singh (2012), effective leadershipin policy implementation is required for the development of evaluation tools for analysis of the public health system, including the burden of disease, use of health services, and effectiveness of health interventions. For the successful implementation of the strategic frameworks for IPC, there is a need for strong leadership, sufficient human and financial resources, and sustainable development of healthcare services (Abdool-Karim et al., 2009).
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According to Naidoo (2012), policy implementation is a challenge in SA’s health system. There is a possibility of formulating a good policy, but there is bad implementation (Carrin et al., 2008). Health policy is described as an official document, a written set of rules and guidelines that provide the information on what actions are considered reasonable and necessary to strengthen and improve the health system. It affects the funding, institutions, organizations, and services of the health system (Gilson, 2012).
Health policy also accommodates the policies made in the public and private sector, since outside factors also influence the health system (Gilson, 2012). A model for explaining implementation simply involves analyzing inputs, outputs, and outcomes, where inputs produce outputs in the form of public policy, and implementation is described as the process by which such outputs are converted into social outcomes (Carrin et al., 2008). Implementation is also viewed as a complex and interactive political process in which a variety of actors guides the direction and execution of a specific policy within the limits of existing institutions (Buse et al., 2005). As a result of the concerns raised on proper implementation of IC procedures at public health facilities in SA (Engelbrecht & Janse van Rensburg, 2013), it is important to analyze whether the NIPCPS is adequately implemented. IPC is described as measures, practices, protocols and procedures intended to inhibit and regulate infections and their transmissions in the healthcare environment (NIPCPS, 2007). These measures are collective interventions and actions such as personnel hygiene, the use of personal protective equipment (PPE), programmes of employees’ immunization, aseptic techniques, waste management, the proper use of antibiotics, and so on (NIPCPS, 2007).
The aim of infection and control guidelines is to provide safe healthcare settings for both patients and staff by ensuring good IC practice which must be established to improve health outcomes and prevent diseases, deaths, escalated healthcare costs and potential lawsuits. The concept of governance comprising the specific roles and responsibilities of national, provincial and local government representatives and civil society on the prevention and management of infections is described and incorporated within these guidelines (NIPCPS, 2007).
The WHO (2007) definition of governance is “ensuring [that] strategic policy frameworks exist and are combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system design, and accountability” (Mikkelsen-Lopez et al., 2011). Governance is concerned with the implementation of the
5
policies and it is an important topic since the concept and descriptions of the health systems formulated explain governance, either in a point of stewardship, regulation, oversight or governance itself (Mikkelsen-Lopez et al., 2011).
Stewardship is one of the four main functions of the health system, the other three being service delivery, financing, and creating and managing resources. It is said to be about trust and legitimacy, where good stewardship is viewed as the core of good governance in health (Siddiqi et al., 2009).
Good governance of the health system is promoted by the assessment of governance. Governance affects all other functions of the health system and results in an enhanced performance of the health system, and eventually in improved health outcomes (Siddiqi et al., 2009). The concept of governance in the health sector is still very new and is composed in reports suggesting that it is an ongoing process, and there is a vast interest in understanding the relationship between governance and health worldwide via discussions on global health governance (Mikkelsen-Lopez et al., 2011).
The current study sought to understand whether the concept of governance played a role in the implementation of the NIPCPS, which was made possible by the application of a suitable health system framework. Siddiqi et al. (2009) present a governance framework that can be used to assess the health system in developing countries, which was relevant to this study.
1.2 Problem statement
The public healthcare sector of SA is the first place of hope where the sick and poor citizens go for treatment. It is also documented in the Bill of Rights that it is a constitutional right for such people to be attended to in the public healthcare sector, but the conditions of these institutions have deteriorated and the service delivery for patients is very poor. Despite the fact that the NDoH of SA has formulated and adopted the Draft NIPC guidelines for TB, MDR-TB and XDR-TB, the NIPCPS and the IPC practices are still poorly implemented in the public health facilities.
Firstly, there is still a shortage of antimicrobial drugs including ART drugs, and this compromises the survival of patients due to the development of resistance to these drugs after treatment interruptions. Secondly, there is an issue of overcrowding, and the lack of hospital beds, which is problematic in the case of management or control of communicable diseases where patients who were supposed to be isolated cannot be as a result of a shortage of beds and space.
6
This makes the management of infections difficult as more patients catch hospital NIs, and the treatment of patients becomes more expensive, which the public healthcare cannot afford. Thirdly, there is the irrefutable issue of the maltreatment of patients, particularly those with HIV and infectious diseases by the staff members of the public healthcare system. The cause of such maltreatment might be largely due to the lack of training in the management of infections on the part of the public healthcare staff.
All of the issues above are documented in the NIPCPS, but the problems persist. This required the analysis of the implementation of such a policy, and the role of governance in such a process in order to arrive at recommendations or solutions to these challenges faced by public healthcare, and eventually result in an improved service delivery.
1.3 Aim and objectives
Subsequent to the identified need for further research, the following aim was formulated as a guiding principle for this study: To explore the role played by governance in the implementation of NIPCPS (2007) in SA’s public healthcare sector.
The specific objectives of the study included the following:
To conduct a multiple-case analysis of the shortage of antimicrobial drugs and its consequences for IPC in the public healthcare sector in SA.
To conduct a multiple-case analysis of overcrowding and the shortage of hospital beds (medical devices), and its consequences for IPC in the public healthcare sector in SA.
To conduct a multiple-case analysis of the maltreatment of patients who have infectious diseases and its consequences for IPC in the public healthcare sector in SA.
1.4 Theoretical framework
The theoretical framework is one of the most crucial components in the research process (Grant & Osanloo, 2014). It guides the study, gives an idea of the research question and assists the researcher in justifying the research problem (Maxwell, 2005).
Specific to this study, the proposed theoretical framework is designed to explore how governance plays a role in the implementation of NIPCPS in SA’s public healthcare sector. The framework used the governance principles including strategic vision, participation and consensus orientation, accountability, ethics, Rule of Law, and effectiveness and efficiency. Figure 1.1 below is the theoretical framework that will guide this study.
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Figure 1.1: Multiple-case study analysis and theoretical framework application
1.5 Structure of this dissertation
This dissertation consists of five chapters Chapter 1
This section provides a background of the study, and explains the problem statement, aims and objectives, methodology, as well as the layout of the study.
Chapter 2
This section covers the health policies prior to the NIPCPS (2007) formulation, and the policies and legislations that support the NIPCPS formulation and implementation. It also provides an overview of the public healthcare sector in SA, explaining its different forms and the challenges it is faced with, and the role that governance plays in public healthcare.
CASE STUDY ON SHORTAGE OF ANTIMICROBIAL
DRUGS
CROSS CASE ANALYSIS- OPEN, ANXIAL & SELECTIVE CODING &
MEMO MAKING THEORY CONSTRUCTION OUTCOMES STUDY OBJECTIVES CASES CASE STUDY ON LACK OF EQUIPMENT & SPACE CASE STUDY ON MISTREATMENT OF PATIENTS NIPCPS (2007) THEORETICAL FRAMEWORK
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Chapter 3
This section of the study provides a review of the methods that are relevant to this study, and describes how the study was conducted.
Chapter 4
This section covers the findings on the multiple-case study analysis of the role of governance in the NIPCPS implementation. This section analyses the NIPCPS in relation to the three study objectives. The findings from a suitable governance framework in relation to the NIPCPS are also reported in this section of the study.
Chapter 5
This section presents the discussion, conclusion, recommendations and study limitations. 1.6 Summary
This chapter provides an introduction to the study and the research objectives. This study aimed to document how governance plays a role in the implementation of the NIPCPS. To fulfil the aim, three objectives were formulated to give direction and focus to the study. The next chapter focuses on literature review, where the documented knowledge about the study is explored to provide insight into the topic of research.
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Chapter 2: The health policy and NIPCPS, public healthcare in SA, challenges, and governance
2. Introduction
The purpose of this chapter is to introduce public healthcare in SA. It begins by describing the policy and health policy, and an overview of the policy-implementation process. Furthermore, it discusses the policies that came into place after 1994, placing more emphasis on the NIPCPS. Secondly, the concept of a health system is explored, followed by categories of existing health systems, the diseases burdening the health system and the key functions that contribute to the improvement of the health system performance. Then, an overview of SA’s post-apartheid public health system is unpacked, particularly facilities of care such as the primary, secondary, and the tertiary levels. The discussion then leads into the role of governance in SA’s public healthcare.
2.1 Policy, public policy and health policy
There have been significant changes in the South African health sector post-1994, and various policies were drafted under appropriate consultation with the significant actors and stakeholders (Dennill et al., 1999). Policy can be defined as resolutions made by policy makers in a certain area, be it health, education, business or environment, in various levels such as local or central government, local company or hospital (Buse et al., 2005). It provides direction for making decisions, enhances stability in management decisions, and can be used in various conditions found in certain circumstances, areas and communities (Dennill et al., 1999).
Policy can impact negatively or positively on the healthcare or health of individuals, communities or the entire population based on what various health and healthcare systems offer or remove (Paton, 2008). After careful analysis of various definitions, Roux (2002) describes public policy as the anticipated way of acting by the government or rules that should be pursued to achieve the purpose and objectives, or the statement of authority on which the government determines actions to undertake or reject, and integrate or involve the reliable sharing of principles for the entire society.
Health policy can be described as the set of actions that affect the health system by impacting on the group of organizations, institutions and financial provisions, and may consist of both governmental and private sector policies (Gilson, 2012). Dennill et al. (1999) explain that a health policy has an impact on the health and disease conditions of the
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country, and thus establishes what the ruling government places on health, as well as the amount of money it gives to health.
The process of public policy (Figure 2.1) involves four consecutive stages, namely setting agenda, formulation, implementation, and analysis (Shiffman, 2008). According to Sutcliffe and Court (2005), the policy process also involves the choice of solution or selection of preferred policy option as well as policy design. Policy pitfalls are mentioned to be in the policy design and implementation processes, where, in the case of the policy design, the limitations include targeting criteria, putting them into action, latent costs; insufficient community involvement; unplanned consequences, such as geographical imbalances and resistance of public servants; and the absence of a monitoring and evaluation system in the majority of policies (Rispel et al., 2010).
According to Rispel et al (2010), the limitations in the policy implementation process include an irregular area implementation that has a more negative impact on rural areas; insufficient administrative and implementation competency; inadequate resources; and an outflow to the wealthy; fraud and corruption problems, poor public servants participation, and worsening implementation ability problems.
According to Buse et al (2005), health policy describes implementation “as what happens between policy expectations and policy results”. The literature on policy implementation suggests that governance is important for opportunity creation, problem-solving and designing structures and mechanisms required for the implementation process (Scott et al., 2014).
It is important to acknowledge that public policy formulation and implementation in the health sector are very much subject to politics. Decisions are made regarding to whom services must be provided, who the service providers are, who will be financially supported, and how budget spending is allocated (Glassman & Buse, 2008).
2.1.1 Policy implementation processes
Alvarez-Rosete (2008) discusses that the process of policy implementation is said to be a top-down process led by the central government, and it requires involvement by local leaders, and its failure is perceived to be a compliance problem at the lower levels of administration. Apart from being a top-down process, policy implementation can also be a bottom-up process, where the front-line staff such as nurses and doctors deliver health services (Buse et al., 2005), or principal-agent theory where the principals hand over
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responsibilities of policy implementation to their officials (public servants in the Health Ministry) (Buse et al., 2005). To ensure the success of the policy implementation process, policy makers must consider the viability of the policy, the availability of resources, the timing, and the ways of measuring policy failure or success, doing all in consultation with the implementers during policy design and development (Alvarez-Rosete, 2008).
Figure 2.1: The public policy cycle
Sutcliffe & Court (2005)
2.1.2 Health-related policy introduction and implementation in post-apartheid SA
Policy implementation is guided by legislation, that is the policy must be drafted first to guide the content of the legislation, and then legislation will be developed to provide a direction for policy implementation (Pillay et al., 2002). Both policy and legislation are plans for implementation, and policy directs the actors on a journey of the implementation plan, whereas legislation provides the whole information on how to go about implementing a plan (Van Rensburg 2012). However, the capacity to formulate and implement policies for the delivery of government health reform programmes has become a great concern, and the process of policy implementation and delivery has proven to be challenging (Hunter & Killoran, 2004).
Healthcare before 1994 was believed to be an opportunity, and not a right, and the people who were eligible were those who had money to pay for it; the wealthy and white people who were medically insured (Van Rensburg 2012). The legislation and institutions of the apartheid era had left an inheritance of continuous poverty, national divisions and tremendous differences over the time of 300 years (Gumede, 2008).
Post 1994, several important policies and legislation related to health reform were rolled out, which are listed in Table 2.1: The National Drug Policy, 1996 (Dennill et al.,1999); The White
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Paper on Transforming Public Service Delivery, 1997(Van Rensburg et al., 2004); National Health Act 61 of 2003 (Van Rensburg et al., 2012); The South African Draft NIPC Guidelines for TB; Multidrug resistant tuberculosis (MDR-TB) and Extensively drug resistant tuberculosis (XDR-TB), 2007; and the NIPCPS, 2007 (Engelbrecht & Janse van Rensburg, 2013) that is established in the Constitution of the Republic of South Africa Act 108 of 1996; and the National Health Act (NHA) 61 of 2003 (NIPCPS, 2007).
Several other important policies and legislation (Figure 2.2) were adopted in the formulation and implementation of the NIPCPS (2007); The Occupational Health and Safety Act 85 of 1993, Hazardous Biological Agents Regulations, The Environment Conservation Act No 73 of 1989, The Foodstuffs, Cosmetics, and Disinfectants Act No 54 of 1972, as well as the NHA 61 of 2003, and the Constitution of the Republic of South Africa Act 108 of 1996 (NIPCPS, 2007). This study focuses on the NIPCPS, which was launched in 2007. The NIPCPS (2007) is aimed at setting the minimum national standards for the appropriate prevention and effective management of NIs in order to ascertain that biological agent hazards are limited for patients, visitors and HCWs (NIPCPS, 2007). An NI, also referred to as HAI, is the kind of infection where there is evidence that upon the patient’s arrival in the healthcare facility there was no infection present, and 48 hours after admission the infection occurs (Perovic & Singh, 2011). NIs comprise a huge number of healthcare problems and lead to increased hospitalization that adds additional expenses to healthcare and also results in more diseases and deaths (Petrosillo et al., 2005).
Therefore, these HAIs must be properly controlled in order to prevent the transmission of organisms amongst patients, HCWs and visitors, especially HCWs and visitors who may be the primary sources of infections that lead to outbreaks. Practising good IC is thus essential to improve health results and preventing negative consequences such as diseases, deaths and possible legal action (NIPCPS, 2007). The programme for IPC covers all features of IPC including surveillance, research on the outbreak, and education, environmental and waste management, formulation and revision of IPC policies, guidelines and procedures, cleaning, disinfection and sterilization, health of HCW and quality IC management (NIPCPS, 2007). Table 2.1 below shows several important policies and legislation related to health reform that were rolled out in SA post 1994. Figure 2.2 below shows several other important policies and legislation that were adopted in the formulation and implementation of the NIPCPS (2007).
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Basic surveillance is a good starting point of IC programmes in that it assists in the calculation of the infections rate, and it provides data that can notify HCWs about the spread of HAIs (Perovic & Singh, 2011). The IPC programme covers the following: medical devices such as hospital beds, radiotherapy machines, contact lenses, condoms, heart valves, syringes, resuscitators, wheelchairs, walking frames, and surgical instruments (NIPCPS, 2007). It also covers respiratory tract equipment, ventilator and bed rails (Saiman & Siegel, 2004), while the PPE (shown in Figure 2.3) encompasses gloves, aprons, gowns, caps, masks and protective eye wear (NIPCPS, 2007).
The appropriate IC practices also include the commitment of HCWs in ensuring careful hand hygiene, correct patient isolation, the use of gloves, and the utilization of sterilized medical devices (Perovic & Singh, 2011). Alcohol-based hand rubs must be used in order to practise proper hand hygiene. However, when the hands look dirty or are covered with blood or body fluids, an antimicrobial-containing soap and water may be used. Other aspects of hand hygiene include caring for the skin of hands and fingernails, which includes discouraging the HCWs from wearing artificial nails since they harbor gram-negative pathogens more than natural nails, even after washing (Saiman & Siegel, 2004).
Appropriate hand hygiene practices require the availability of soap and water at locations convenient to HCWs (Perovic & Singh, 2011). The NIPCPS is based on the principles such as prevention, privacy, occupational health and safety, as well as integration, and prevention (NIPCPS, 2007). Section 8 of the NIPCPS discusses that there should be infection prevention interventions, patients’ and HCWs’ rights to privacy should be upheld, the health and safety of HCWs will be considered. It further describes that IPC programmes will be integrated with programmes such as TB, comprehensive care, control of communicable diseases, and Environmental and Occupational Health ( NIPCPS, 2007).
In addition to this document, there are guidelines for SA’s Draft for NIPC guidelines for TB, MDR-TB and XDR-TB and the NIPCPS (Engelbrecht &Van Rensburg, 2013). The draft NIPC policy for TB, MDRTB and XDR-TB was developed to assist the HCW, both
management and staff with reducing the TB transmission risk within the institutions of healthcare and in other facilities where there is a potential for high TB transmission as a
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Figure 2.3: A picture of PPE
World Health Organization (2003)
The policy covers issues including the procedures for the IPC to reduce the risk of the transmission of MTB in healthcare facilities, significance of controlling TB in drug rehabilitation centres, and correctional institutions including prisons, other detention centres and other facilities where a great numbers of possible TB and HIV infected individuals are found. It also covers TB and extensively drug-resistant XDR-TB (The draft NICP policy for TB, MDR-TB and XDR-MDR-TB, 2007).
According to WHO 2003, TB results from the MTB infection that affects one third of the people in the whole world, and concern is particularly on the rise concerning drug-resistant TB and MDR-TB. MDR-TB is the form of TB that is resistant to any combination of Isoniazid and Rifampicin (WHO, 2003), while XDR-TB is described as the form of TB that is resistant to isoniazid, rifampicin, quinolones, and at least 1 of 3 second-line drugs that are administered intravenously (i.e., kanamycin, capreomycin, or amikacin).
Drug-resistant TB is caused by insufficient treatment therapy that allows the selection and growth of the naturally occurring resistant strains or by the infection with primary drug- resistant strain of TB (Andrews et al., 2007). Prior to the launch of the TB IC programme, there had been reported outbreak cases of MDR-TB and XDR-TB in SA, where 39% of patients had MDR-TB, of which 53 had XDR-TB in a rural hospital in the KwaZulu-Natal Province in 2006.
The outbreak cases of XDR-TB had continued to increase to 266 in a rural KwaZulu-Natal district in 2007 with a death rate of 84%, and the XDR-TB cases were reported in patients attending about 60 various health facilities in the KwaZulu-Natal Province and in all other
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nine provinces of SA (Abdool Karim et al., 2009). XDR-TB isolates have been identified in more than 40 institutions of healthcare across the province and in every province in the country (Andrews et al., 2007).
Churchyard et al (2014) mention that the major pillars of TB control are finding, treating and preventing TB in order to minimize TB transmission and associated mortalities. It was the purpose of the TB Strategic Plan for SA (2007-2011) to concentrate on TB and HIV, MDR and XDR-TB, and to empower TB-infected people and their communities to organize and implement TB research and IC strengthening (Abdool Karim et al., 2009). However, the IC guidelines are still poorly implemented, and there is a need of regular monitoring of healthcare institutions to make sure that IC guidelines are constantly implemented. Proper TB IC is not only essential for people at high risk of exposure such as HIV-infected people and children, but also HCWs who are at risk of contracting nosocomial TB (Churchyard et al., 2014).
Engelbrecht and Van Rensburg (2013) argue that the high incidence of TB in SA could partly be a result of poor IC in public healthcare facilities. Reports from research have raised the alarm around the issue of implementation of IC practices in public healthcare institutions, and when compared with the levels of IC stipulated by WHO, SA was identified as having a number of poorly implemented practices at the facility level (Engelbrecht &Van Rensburg, 2013).
Indicators of failing to meet the criteria of implementing the IPC measures in SA’s public healthcare includes the absence of IPC committees , absence of policies, absence of an IC staff member in charge, and insufficient IC practices. Inadequate IC measures include the failure to isolate patients who are TB infected from those that do not have TB, insufficient screening of TB and triaging of patients, carrying the collection of sputum inside facilities or no formal sputum collection areas.
Other factors include the poorly implemented environmental control practice such as not using natural ventilation and not having the personal protective measures due to staff members lacking skills in the use of N95 respirators. There is also the challenge of not having surgical masks and respirators at some facilities (Engelbrecht & Van Rensburg, 2013).
2.2 The healthcare system in general
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wellbeing, and not merely the absence of disease and infirmity (De Haan, 2005). Public health is affected by a certain group of programmes and activities that are employed to make a change to ensure better health promotion, ill health prevention, as well as a safe environmental health (Carrin et al., 2008). On the other hand, the health system is the structuring of people and facilities to convey specialized knowledge and skills to individuals, groups of individuals, or their surroundings to advance, protect or preserve their health (Van Rensburg et al., 1992). The WHO describes health systems as those consisting of all institutions, organizations and resources dedicated to making an impact mainly with the aim of improving population health (Hunter, 2008). Another description of a health system is an institution of healthcare, where healthcare is the complete collaborated actions taken in response to the existence of the disease, and for counteracting the risks to health – this includes patients and communities (Van Rensburg et al., 2012).
There is a national and a total health system (Van Rensburg et al., 2004). The national health system (NHS) includes the ‘policies, programmes, institutions’ and players that offer healthcare which consists of combined actions to cure and inhibit disease. The total health system includes the entire NHS and all matters related to health, particularly the environment around the health system, and the people receiving healthcare services from that particular health system (Van Rensburg et al., 2012; Van Rensburg et al., 2004). The functioning of the health system depends on its ability to carry out four key functions, namely stewardship, financing, service delivery, and resource creation (Engelbrecht & Crisp, 2010; Hunter, 2008). Figure 2.4 below shows the above-mentioned critical functions necessary for the improvement of the health systems.
Figure 2.4: Health system performance model: relationship between key functions and respective objectives
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Stewardship is the responsible management of what is placed under one’s care, and it has an impact on policies and deeds in all the aspects that may affect people’s health. It is the most crucial function of governments, and it indicates the ability to create and implement directive policy plans that can ensure a good health system performance that has accountability and transparency (Hunter, 2008). On the other hand, financing in the health system involves the strategies used to collect an income, gathering and sharing it among the healthcare providers to improve health. Stewardship assists most health systems to enhance social unity and the protection of finances (Hunter, 2008).
Service delivery in healthcare is a function that ensures the availability to care among all groups of people in order to address inequality, while making sure that the total population is covered, promoting the safety of patients, and being aware of various service delivery plans in the health system (Hunter, 2008). Good service delivery is an important element of every health system, and it is a major input to the health status of the people. The network of service delivery in a well-operating health system should include the following main features: comprehensiveness, accessibility, coverage, continuity, quality, person-centredness, coordination, accountability and efficiency (WHO, 2008). Health system resources include the following (Hunter, 2008):
Financial resources, Human resources,
Universities and educational institutions, Research centres, and
Companies that manufacture healthcare technologies such as drugs and medical equipment.
Regarding the last point, resource generation in the health system involves investing to obtain a maximum balance between resources and new medical technologies (Hunter, 2008).
Gilson (2012) also highlights the health system building blocks (shown in Figure 2.5) that influence the performance of the health system, dividing them into the hardware and software, where the hardware includes the specific organization, policy, financing and legitimate structures that make up any health system, and also its clinical and service delivery needs.
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Figure 2.5: Health system building blocks
Mikkelsen-Lopez et al (2011)
The WHO broadens this term ”hardware” to include information systems, and types of human resources, and governance, and also recognizes the inclusion of the policy suppliers, services, interventions, and the citizens that partake in policy change (Sheikh et al., 2011). In contrast, software involves the principles, values, roles, and duties of the institution enshrined within the system.
Sheikh et al. (2011) in Figure 2.6 gives an illustration of the hardware and software concepts in the system, complex system, and social construction. This shows the alternative complex health system formulations that can be affected by the economic theories of political organizations and markets. Thus, making conclusion to non-linear, and dynamic relationships between different parts of health systems, and to the role of software and hardware of systems (Sheikh et al., 2011). The mentioned key functions and building blocks have been used to study how to improve the health system of SA (Engelbrecht & Crisp, 2010).
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Figure 2.6: Alternative perspective to health system performance
Sheikh et al (2011)
2.3 SA’s public healthcare system
In 1994, SA became a democratic country, and its democratic government acquired a highly segmented health system that was based on differences in the access and quality of medical care between black and white people, urban and rural residents, and the public and private health sectors (Rispel et al., 2010). In SA, the right to healthcare is a basic human right for all citizens, and it is also the foundation of the current health system (Dambisi & Modipa, 2009; De Haan et al., 2005; South African Constitution 1996). The health system in SA provides the primary, secondary and tertiary levels of care, through the clinics, district, tertiary or academic hospitals (Van Rensburg et al., 2004).
It is the responsibility of the South African government to make sure that health services are accessible to all citizens using the primary healthcare (PHC) approach (Dennill et al., 1999). The public sector provides health services to approximately 84% of the population of whom the majority are black and poor people (Naidoo, 2012). SA’s healthcare carries a large burden of diseases, and has poor returns on health when compared with other middle-income countries (Rispel et al., 2015).
2.3.1 Quadruple disease burden crippling SA’s public healthcare system
The disease profile in SA is a complex one, and it is a quadruple burden of disease (Naidoo, 2012). It consists of HIV/ AIDS and TB, maternal and childhood diseases, non-communicable diseases (including obesity, diabetes, hypertension, non-infective respiratory
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diseases, musculoskeletal disorders, and dermatological diseases), and violence and escalated risks of injuries (Naidoo, 2012; Rispel & Barron, 2010). Van Rensburg et al (2004) describe the three-fold challenge of infectious diseases, chronic lifestyle diseases, and trauma and injuries that place high demands on the insufficient health resources.
2.3.2 IC of communicable diseases as part of the burden crippling SA’s public healthcare system
The epidemic infectious diseases are occurring simultaneously with escalated non-communicable diseases in SA’s healthcare system (Mayosi et al., 2009). HAIs affect hundreds of millions of people globally (Pittet et al., 2008). HAIs and their control are a global challenge (Alp et al., 2011), and it appears to be clear that IPC falls short in public health facilities in SA (Visser et al., 2011). Key reasons for this shortfall are a lack of IC practitioners, as well as a lack of training among practitioners (Visser et al., 2011). Other factors include overcrowding (due to lack of space) which influences the spread of HAIs (Kaier et al., 2012); lack of equipment (Tirivanhu et al., 2014), soap and disposable towels for good hygiene and PPE, particularly N95 masks (Engelbrecht et al., 2015). In addition, insufficient medical and medicinal resources hamper the implementation of basic IC programmes in healthcare facilities (Dusé, 2005).
2.3.2.1 IC globally
Regardless of the era of successful prevention and control efforts, infectious diseases are still a global problem in public health (Cohen, 2000). The prevalence of HAIs as reported by the WHO at any given time varies between 3.5 and 12 % in developed countries, and between 5.7 and 19.1 % in developing countries (Engelbrecht et al., 2016). These HAIs result in increased hospital stay, long-term disability, increased antimicrobial resistance (AMR), huge additional financial burden, high costs for patients and their family, and excess deaths (Pittet et al., 2008).
HAI rates lowering strategies are centralized particularly on expanding the implementation of standard IPC precautions (Edwards et al., 2012).To prevent and control these infections, it is necessary to have the suitable infrastructure as well as proper human and financial resources, which is country dependent in terms of allocation of these resources to such programmes (Cardo & Soule, 1999).
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(1) The collaborated Healthcare Epidemiology of America, Inc/Association for Professionals in IC, Inc/Centers for Disease Control and Prevention Consensus Panel Report initiative that comprises three goals for hospital IPC including (Cardo & Soule, 1999):
Protection of patient; HCW protection,
Protection of visitors of the healthcare environment, and
To by all means achieve these two mentioned goals in a cost-effective manner, whenever possible.
(2) The “Clean Care is Safer Care” WHO Global Patient Safety Challenge (2004) that is meant to (Carlet et al., 2012):
Provide guidance,
Enhance hand hygiene support initiatives globally, including in developing countries. (3) The Challenge “Clean Care is Safer Care” (2005–2006) aimed at (Pittet & Donaldson, 2005):
Promoting awareness of the influence of HAIs and to promote country-based preventive strategies,
To establish the commitment from countries to prioritize minimizing HAIs, and
To evaluate the new WHO Guidelines on Hand Hygiene in HealthCare (advanced draft) implementation in certain districts globally as part of an incorporated package of activities derived from existing WHO strategies in the areas such as clean products, practices, equipment and the environment.
(4) The Joint WHO-ILO-UNAIDS Policy Guidelines (2010) aimed at enhancing (Yassi et al., 2016):
HCWs access to HIV and TB Prevention, Treatment, care and support
to stress the significance of strengthening IC programmes, guaranteeing a work environment that is safe for health workers.
2.3.2.2 IC SADAC
African developing countries rank the highest in infection rate (Ehlert et al., 2014) and SA is identified as having a huge burden of infectious disease in addition to HIV and TB (Ehlert et al., 2014; Pearse, 1997). Regardless of some challenges, there are promising signs that the significance of HAI is being recognized in Africa (Nejad et al., 2011). Even though many
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African countries struggle with infrastructure to handle surveillance of the new resistant bacterial strains emerging from irrational use of antibiotics (Pearse, 1997), there is a progress in IPC.
In Zimbabwe, IPC was shown to be possible and economical, through teaching the villagers the basic hygiene, home nursing, construction of fly-proof pit toilets, and a safe water supply (Pearse, 1997).
The study conducted in Algeria (2001) has revealed how the introduction of a prevention programme at the facility level has decreased the prevalence of HAI hospital-wide over five successive years (2001–2005) (Nejad et al., 2011).
The implemented standardized protocol for surgical wound management in Uganda has enormously decreased surgical site infection after caesarean section (Nejad et al., 2011).
The improvement of infection prevention has been started nationally in some countries, such as Senegal, where a national programme to reduce HAI (Programme
national de lutte contre les infections nosocomiales [PRONALIN]), was implemented
in 2004, and has become a template for similar programmes in other neighbouring countries (Nejad et al., 2011).
The IPC Africa Network and the Réseau international pour la planification et l’amélioration
de la qualité et de la sécurité dans les systèmes de santé en Afrique organize regional and
international IPC efforts (Nejad et al., 2011), and the IC Association of Southern Africa provides information, standards, and a support base, and has the "IC Manual" which equips managers with the guidelines and basic knowledge for IPC (Pearse, 1997).
2.3.2.3 IC SA
In SA, IPC is receiving more attention after being a neglected area in the medical field, and the national Minister of Health, Dr Aaron Motsoaledi identified it as one of the priorities in healthcare (Visser et al., 2011). The national and IC guidelines have been adapted in SA (Farley et al., 2012). The IPC guidelines cover topics like staffing, policies, training, additional resources, current problems and potential solutions (Visser et al., 2011). The SA guidelines are tailored to also cover five important challenges such as AMR, nosocomial pneumonia, bloodstream infections, urinary and intra-abdominal tract infections, and are meant to minimize the effect of these challenges on patient outcomes (Dusé, 2005).
The Infection Control Society of Southern Africa (ICSSA) was established to promote IC countrywide particularly through the establishment and support of local ‘chapters’, but it is
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hard to sustain these local chapters (Visser et al., 2011). In 2011, there were three established local IC societies: Western Cape, Gauteng and Pretoria. In the Free State, communication with society members was conducted electronically, but the meetings were no longer held where individuals are able to attend. The Kwazulu-Natal chapter had trouble since the IPC practitioners were given the task of re-forming the chapter (Visser et al., 2011).
In an effort to protect HCWs from infectious diseases and promote safe working conditions, SA has formed a partnership with Canada (2006) where occupational health and IC experts formed collaboration with a nationwide mandate to undertake research and establish guidelines (Yassi et al., 2016).
2.3.2.4 Lack of antimicrobial drugs and IC
Drug shortages create a serious problem for institutions of healthcare, and frequently interfere with patient care. Since the early 2000s, drug shortages have been increasing and identified effects caused by these drug shortages include disability; the need for intervention; and deaths of patients (McLaughlin et al., 2013). Incorrect antibiotics use and antibiotic underuse increases AMR (Carlet et al., 2012; Odonkor & Addo, 2011). Inappropriate and irrational antimicrobial uses empower the emergence, spread and continuation of resistant microorganisms (Odonkor & Addo, 2011). Although antibiotic resistance may emerge through antibiotic selection pressure, it is worsened by risk factors such as poor IC (Essack, 2006). Therefore, coordination of IC with antibiotic stewardship must be strongly emphasized (Carlet et al., 2012).
2.3.2.5 Lack of healthcare space and equipment and IC
Patient overcrowding has been reported to be among the factors that increase infectious diseases transmission within hospitals (Kaier et al., 2012; Virtanen et al., 2011), but it is difficult to dispute against the probability of overcrowding being a result of the breakdown in IPC practices (Visser et al., 2011). At the public health facilities in SA, the poorly implemented IPC measures have been identified to include failure to separate patients with TB from those without it; and a lack of IC equipment (surgical masks and respirators) which are not always available at certain facilities (Engelbrecht & J van Rensburg, 2013).
2.3.2.6 Poor treatment of patients by health workers, and IC
Other problems faced by the health system in SA associated with the human resource is unprofessional behaviour, poor staff motivation, and poor treatment of patients by health
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workers , as well as the insufficient human resource information system that is failing to notify human resources with regard to planning and training (Rispel, 2016). The human resource of the health system in SA is also burdened by communicable and non-communicable diseases which affect HCWs from clinical to laboratory staff, general assistants, and administrators, and there is a growing need to manage diseases in the HCWs of the South African health facilities (Naidoo et al., 2016).
2.3.3 Other challenges faced by SA’s public healthcare system
In an effort to combat problems that have long burdened the South African health system, the current health system reforms focus on enhancing health services and the health system performance (Rispel et al., 2015). SA, like other countries, had also adopted the WHO Millennium Development Goals (MDGs), and an overview of the key aspects of performance of the SA health system that are likely to influence the disease control priorities initiative has been performed (Rispel & Barron, 2010).
In assessing the performance of the South African health system, Rispel and Colleague (2010) examined the health system building blocks of service delivery, namely human resources, finances, medical products, vaccines and technology, information, and leadership and governance. They determined the key issues or challenges affecting service delivery associated with the health system building blocks, and they have highlighted that there is a need for good leadership that can prioritize the efforts needed to improve the health status and health system of SA. Zweigenthal et al (2016) have looked at the workforce and described the barriers to improved health services as the shortage of staff, insufficient numbers of training staff, career changing, and so forth.
The health system in SA also suffers in the area of leadership where the problem is described to be due to a lack of stewardship, exacerbated by a lack of accountability, incompetence, governance failures, and corruption (Rispel, 2015). Rispel et al (2015) have concluded that poor leadership has a common relationship with corruption, and that this contributes negatively to the morale of healthcare providers, and they further named one method of corruption detection called agent selection. When looking at financing as the building block of service delivery in the health system, the key challenges determined include financial management and accountability, as well as the costing of health sector services, which is poor (Rispel & Barron, 2010).
Rispel (2015) concludes that the answers to these problems in human resources, financing and leadership lie in the appointment of competent and qualified public service managers.
